| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
362 |
362 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
256 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
41 |
$3K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$861.50 |